Application Form For s1

Application form for: I. Burkhalter New Investigator Grant for Clinical Research in Hand and Upper Limb Rehabilitation. II. Judy Bell Krotoski Grab the Evidence Grant for Fundamental Research and Evidence-based Studies. III. ASHT Founder’s Grant General instructions:  Review the grant description for purpose of the grant and procedures.  Format of application:  Use an Arial, Helvetica, Palatino Linotype or Georgia typeface, Times New Roman, a black font color, and a font size of 12 points or larger. A symbol font may be used to insert Greek letters or special characters; the font size requirement still applies. Use normal margins, single spaced or larger.  For additional information, contact the Director of Grants, Mia Erickson, PT, EdD, CHT at [email protected].  Please, adhere to the page limits listed below:

Indicate the Grant applied for: “Burkhalter” OR “Judy Bell” OR ASHT Founder’s Face page Grant Project summary: 1 page Include aims, significance, relevance, innovation, investigators and environment, and amount requested. Biosketch/ Curriculum Vita of Principal Investigator (PI) and each key 4 pages or personnel. Highlight the areas important for the application. less Include: (a) Personal statement describing the role and the expertise for the role in the project, (b) positions and honors, (c) pertinent publications and refereed presentations, (d) ongoing research support/funding, (e) completed research support/funding, (f) continuing education as pertinent for the project Budget: include an itemized budget with a budget justification for each 2 pages requested item Research plan 15 pages Introduction and background information: include (a) significance, (b) relevance 4 pages and innovation for hand rehabilitation Specific aims, research questions and hypotheses: use SMART goal format; 1 page include primary and secondary measures

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson Research Strategy (methods): Include (a) study design, (b) inclusion and 10 pages exclusion criteria of subjects/participants, (c) power analysis to substantiate number of subjects, (d) if applicable intervention procedures, (e) measurement procedures including scientific evidence of reliability and validity of used measures, (f) planned statistical analyses. For qualitative projects: Include (a) the type of qualitative study, (b) inclusion and exclusion criteria of the subjects/participants, (c) substantiate how the planned number and type of subjects will ensure that the data will generate potential for meaningful interpretations, (d) if applicable intervention procedures, (e) interview procedures including methods to ensure reliability, consistency of finding themes, (f) planned analyses. Resources of facility 1 page Time line to complete the project 1 page Expected outcomes and plan for dissemination of results 1 page References No limit Additional information:  Human subject information. Include a copy of the human subject’s 1 page approval if this was already obtained  Appendices: No page limit; elaborations on the research plan are not allowed. No page limitation for included measurement tools or pertinent additional information.

Specific format information: I. Cover page: Add title of the grant application Names of the Principal Investigator (PI) and co-investigators Participating practice and/or institutions

II. Table of contents with page numbers. Page numbers A. Face page B. Project summary C. List of PI and other key personnel with their role on the project D. Resources E. Biosketches of PI and key personnel F. Budget

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson G. Budget justification H. Research plan I. Time line J. Expected outcomes, plan for dissemination of results K. References L. Appendices

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson III. Project description: See below (A through K) A. Face page 1. Title of the project: 2. Name of Grant: Burkhalter or Judy Bell or ASHT Founder’s Grant 3. Information Principal Investigator Name: Last, middle first Degrees:

Contact information (mail, email, phone, fax) OT/PT Licensure ASHT membership Applicant organization:

4. Information time table of project Project start date: Anticipated completion date: 5. Human subject information Human subjects included: Human subject approval obtained: Yes no Yes: date no 5. Applicant organization Applicant organization Type of organization: Name: Private: Address: Public: (local, state, national

Administrative official to be notified if award is Official signing for applicant organization made (applicant needs to notify grant review chair) Signature: Name: Contact information: Name: Contact information:

6. Previous funding obtained for the project: Yes No

If yes, specify the funding source and indicate the start and stop date of the funding.

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson B. Project summary Summarize all components of the project. (Up to one page) Include: Goals/aims or hypotheses; significance, relevance for hand and upper limb rehabilitation, innovation, research strategy (methods), investigators, environment and justification for requested moneys.

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson C. Principal Investigator, co-investigators and their roles on the project Key personnel Role on the project Email or phone contact information Principal Investigator

Co-investigator

Add more lines as needed

D. Resources (up to one page) List space, and equipment available for the project. Also, indicate from where subjects for the project may be recruited.

Space Equipment Patient recruitment Other resources

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson E. Biographical Sketch template. Submit one for the PI and each key personnel

Name Title Current country of residence Education Institution and location Degree MM/YY Field of study

Licensure: Date, location, expiration date

Specialization certificated: Type, date and expiration date

Professional experience (work and professional service) Practice/ Institution Role Years Field of practice location

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Personal statement:

Positions and honors:

Peer-reviewed publications:

Peer reviewed presentations:

Current research support:

Completed research support:

Pertinent continuing education:

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson F. Budget (Budget and Budget justification up to 2 pages)

Allowable expenses: As stated in the grant description of the Burkhalter award. *Note: Authorized use of funds: consultants, equipment, supplies, patient care costs or other itemized expenses related to completing the project. Unauthorized use of funds: salary of the principal investigator, travel expenses, start-up equipment such as computers or basic computer programs (e.g. SPSS, Office, etc). Items that are provided by the facility or investigators may be listed as “in kind” Budget item Estimated expense (as provided by vendor)

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G. Budget justification

Add additional space if needed

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson H. Research plan: Total 15 pages Introduction and Background (4 pages)

Add up to 4 pages as needed.

Specific aims, research questions and hypotheses: one page. No hypotheses are needed to qualitative projects, . Use SMART goal format; include primary and secondary measures (SMART: Specific, Measurable, Achievable, Relevant and Timely).

Add up to one page as needed

Research Strategy (methods): up to 10 pages

Include study design, inclusion and exclusion criteria of subjects, power analysis to substantiate number of subjects, procedures of interventions (if applicable), procedures for measurement (with detailed evidence of reliability and validity of used measures), and statistical analyses.

For randomized trials, you may want to use the CONSORT website as a resource: http://www.consort-statement.org/. Good information is also available at www.nih.gov.

Add up to 10 pages

I. Time line Time line: Up to one page

Add up to one page

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson J. Expected outcomes and plan for dissemination of the results. (up to one page) Expected outcomes: Include what knowledge will be gained from the project. You may also include expected career outcomes. Include planned presentations, naming the meetings and locations and anticipated journal submissions

K. References: Use AMA or APA format, or format used by the Journal of Hand Therapy. (no page limit)

L. Appendices Additional appendices as needed. Only include appendices needed for the application, not to make up for exceeding the page limit.

Review Criteria: Points will be provided for each section Significance Innovation Approach (methods and measurement) Environment Investigator(s) Protections for human subjects Potential for publication in refereed, indexed journals. Potential for subsequent funding – for example, establish the necessary groundwork for larger intervention studies and subsequent funding. Budget and budget justification

Burkhalter/Bell/ASHT application form revised 11/2016 MErickson